A nurse on a postpartum unit is caring for a client. For each finding, click to specify if the finding is consistent with uterine atony or infection.

Exhibits

Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row. Note: Each column must have at least 1 response option selected

Rationale:

A. A client who has heart failure and received a diuretic 30 min ago: While this client should be monitored for urine output and signs of dehydration or electrolyte imbalance, there is no indication of acute distress requiring immediate attention.

B. A client who has hypertension and reports a severe headache: This could indicate a hypertensive crisis or impending stroke, both of which are life-threatening and require urgent assessment and intervention to prevent neurological damage or organ failure.

C. A client who reports frequent and painful urination: These are signs of a urinary tract infection, which, while uncomfortable, is not typically emergent unless accompanied by fever, flank pain, or systemic symptoms.

D. A client who reports left arm pain following a fall: The arm pain may indicate a fracture, but it is less urgent than potential end-organ damage from a hypertensive emergency, assuming no deformity or vascular compromise is described.

Rationale:

A. Ask an experienced nurse to assist with the procedure: Seeking guidance from an experienced nurse supports safe practice and skill development. It ensures the procedure is performed correctly while providing an opportunity for supervised learning, which is appropriate for a newly licensed nurse.

B. Delegate the task to an assistive personnel: Tracheal suctioning is a sterile and invasive procedure that requires the clinical judgment and skills of a registered nurse. It should not be delegated to assistive personnel who are not trained or licensed to perform such procedures.

C. Refuse to take the assignment: Refusing the assignment without attempting to seek help or learn is not a constructive or professional approach. Nurses are expected to seek support when performing unfamiliar but appropriate tasks within their role.

D. Identify that the task is in the scope of RN practice and perform the suctioning: While it is within the RN scope, performing a skill without training or supervision may compromise patient safety. Competence must be demonstrated or developed with supervision before performing independently.